On the appetite in insanity [electronic resource]

Reprinted from " The Journal of Mental Science" July, 1886.

ON THE APPETITE IN INSANITY.

By J. A. CAMPBELL, M.D., F.K.S.Edin.,
Medical Superintendent, Counties Asylum, Carlisle.

(Read at the Carlisle meeting of the Medico-Psychological Association,

April 8th, 1886.J

Z

In submitting tlie following short paper, I do so clearly
realizing that deductions from limited observations present
many sources of fallacy ; also that even extended observa-
tions made in a limited area are very liable to error, and
need correction by extended observation ; that peculiarities
of race, and circumstances connected with locality may even
in such a matter as this exercise a marked influence. I trust,
however, to hear the experience of others on the subject.

In speaking of normal appetite I take what appears to me
the common-sense view of the term, i.e., a normal appetite
is the appetite at varying ages of a healthy person located
in health-retaining surroundings, and enjoying with regu-
larity a sufficient and proper amount of outdoor exercise in a
temperate climate.

Appetite in health is, as we all know, easily affected, even
by slight causes. Previous excesses produce in many what
is in common parlance called a bilious attack, and even
stopping short of this, a want of appetite for a day or two.
The effects of certain mental feelings and states in those
who are sane also affect the appetite ; excitement, joy, grief,
expectation, even surprise, have been known by experience
in many individuals to do away with appetite for a time.

Ordinary physical diseases exercise a' great influence on
the appetite, and during the initiatory stages of most diseases

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On the Appetite in Insanity,

a marked want of appetite is present. Yet there are certain
diseases in which an excess of waste takes place in which
the contrary is observed, as in diabetes, and there are certain
states recognised as natural in which perversities, of appetite
are common, as in pregnancy, while in the borderland cases
of hysteria the vagaries of appetite have been much written
about, and in very many physical diseases the appetite is
uncertain, irregular, and capricious, as in phthisis. In cer-
tain persons a craving is at times felt for certain kinds of
food or vegetables, and, even among the sane, dislike of what
was at one time much relished is often observable.

The varying tastes of varying ages as to food-supply is
well known. Even in children there is a vast difference in
the appetite for different forms of diet, some having a keen
desire and appetite for flesh food, while in others this is
almost entirely wanting.

The extraordinary appetites of certain nations for what
would be revolting to others is no doubt in many instances as
much the result of climatic and natural calls from the system
as anything else. The taste of the Esquimaux for half-
putrid blubber, oil and fats generally, and no doubt the high
seasonings which are so much in use in hot climates, from
the curry of the Indies, to the assafoetida in use as a condi-
ment in Persia, could be rationally accounted for not merely
as an acquired taste, but a supplying of some required want,
if the matter was closely investigated. Natural longings for
articles of diet meet now with considerable attention. At
one time in the history of medicine, when sickness occurred,
the sufferer usually got none of the things he felt a desire
for, hardly even cold water ; nowadays the tendency seems
to be that what you feel an appetite for is what will be good
for you, a much more pleasant doctrine, and probably as safe
as the other.

Seeing what variations take place in the appetite in the
sane, even in health, and much more so in disease which
does not to a great extent affect the mind, it is not extraor-
dinary that very marked alterations in this function should
be met with in insanity.

In glancing at the indices of six recognised text-books on
insanity I find that appetite does not find a place in three ;
in three it does : in Griesinger it is shortly treated of, in
Maudsley perverted appetites are dealt with, and in Buck-
nill and Tuke an analysis of the state of the appetite in 50

by J. A. Campbell, M.D.

3

maniacal cases by Dr. Jacobi is quoted, showing that in 23
of the 50 only it was normal.

Of course, in dealing with the different varieties, the sub-
ject is dealt with. There are certain recognised and well-
marked abnormalities of appetite recorded by all observers
in given forms of insanity, viz. : —

1 . The voracity of General Paralysis.

2. The same to a slighter extent in Epilepsy.

3. The same in certain cases of Chronic Mania.

4. Want of appetite in Melancholia.

5. Cases of Mania in which certain delusions are of such
potency that they overcome the natural feelings of hunger.

6. Extraordinary voracity, with persistent thinness, in
cases of Masturbation.

7. Certain cases of intense excitement, in which the patient
talks so rapidly that he has not even time to swallow.

8. Certain cases in which the excitement is so intense that
it seems to prevent the absorbents of the stomach and intes-
tines from acting.

9. Perverted Appetites in several forms of insanity, when
all sorts of things abominable and indigestible are swallowed.

Before entering into details, or treating of these special
headings which I have given, I may roughly express the
views which a long experience and a careful general obser-
vation have forced on my mind. The population from which
the asylum inhabitants in Cumberland and Westmoreland
are received live, as a rule, fairly well, and are fond, not
only of good food, but of a sufficient supply of it. They are
well-grown men and women, and have been accustomed to a
nourishing and filling diet, yet my experience is that the
recent insane take their food very badly, in many cases re-
fuse it, and this, as far as I can learn, to a greater extent
than in many other districts. A great number of the patients
admitted here in the early part of their attack seem to want
appetite, to loathe food, and in very many cases this is a
source of very considerable trouble in their early treatment.

During early convalescence appetite returns with vigour,
and frequently for a short time the patient eats voraciously.
Ultimately the appetite decreases to its normal standard. I
have exchanged opinions on this matter with numerous
asylum physicians. Dr. Eorie, Dundee, some years ago told
me that he had little or no trouble about making his patients
take their food, and that up to that date he had not required

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On the Appetite in Insanity,

to use mechanical aid for forced alimentation. Several Irish
superintendents have told me that their patients, who, as a
rule, did not fare too sumptuously when at home, nearly
always took food well in the asylum, and that complete re-
fusal of food or necessity for forced alimentation was almost
entirely unknown. I have, however, ceased to he surprised
at incongruities in Irish affairs ! The frequency of crimes
and injuries in Ireland outside asylums, their paucity in
asylums, must strike anyone who studies the subject. I
know asylums in Great Britain in which more concatena-
tions (this, I think, is the term used by the Scotch Commis-
sioners for evils we care not to name) have frequently occurred
in one year than in all the Irish asylums put together.
In the Report for 1883 the Irish Inspectors are able to
state that no death occurred from accident, violence, or
suicide during the past year in the Irish asylums.

As I believe 1 shall show you, when 1 discuss the matter
in detail, my experience is totally at variance with that of
the Scotch Deputy-Commissioners. Their reports would
lead one to think that the summum bonum of earthly bliss
consists in being a boarded- out dement and being cheaply
kept. Dr. Lawson gives a diet scale, in which the whole
weekly expenditure of a patient amounted to 3s. Ofd. a
week for food, lodgings, &c, or rather total main-
tenance. My experience — and it now extends over 20
years — is that dements as a class have appetites greater
than curable insane or than sane, and that in England the
difference in diet scale is a principal cause of deterioration
in mental state, physique, and habits when such cases are
sent to workhouses. The food supply is under the demand.

This view is strongly expressed in the report for 1885 of
Dr. Grierson, the sagacious and kindly superintendent of the
Roxburgh Asylum, as regards the patients boai'ded out from
his asylum.

I have gone over the patients in this asylum, which is
worked greatly on the block system. I find iu one portion
containing 67 male dements, of whom only three have been
less than eight years in the same building, that in all, the
appetite is constantly good and regular, and, although the
diet is ample, hardly anything is ever left from any meal.

The same occurs in another block with 82 patients, where
the patients are of the best class of chronics, with a few
convalescents ; and in two similar blocks on the female side,
containing 50 and 65 patients, the results are very similar.

by J. A. Campbell, M.D.

5

I, however, find a very different state of matters to exist
in the recent cases. I have examined into the last 50
admissions of public patients from these two counties, male
and female, with the following results : Of the males 25 took
food ill, and required pressure, five almost completely refused
food at first, two had voracious appetites, one had perverted
appetite, and in only 17 was the appetite normal.

Of the females 32 had bad appetites, and were got to
take food with some trouble ; 18 had normal appetite.

Of course it is only by exchanging opinions that we can
arrive at general conclusions on such subjects. I think,
however, that physical illness is very frequently concomitant
with disordered mental action, in the public patients re-
ceived into Carlisle Asylum more so, I think, than is the
case in many asylums, and to this is partly perhaps due the
high recovery rate which we have had for many years.

During the four years ending 1882, I admitted 495
patients ; of these 38 per cent, required and received tonic
treatment.

During 1885 sixty-two males were admitted from these
two counties, 25 required immediate tonic treatment ; fifty-
one females, of whom 25 required tonic treatment — 44 per
cent, of the admissions.

I shall now conclude with some remarks on the special
headings I have mentioned.

1 . In General Paralysis the voracity is well known ;
patients bolt their food without regard to the size or heat of
the viands, yet in my experience, as a rule, they confine them-
selves to articles of real food, and though they secrete and
hide stones, &c, under the delusion that they are jewels
and other valuables, this class of patient rarely eats cloth-
ing or dirt. In my experience I find it advisable at a very
early stage to put these patients on special diet. We use
here mince meat with potatoes two days in the week, broth
and milk diet on the remainder, and restrict the food to a
given allowance. I think it better that general paralytics
should not be allowed to get very fat, as if they do they have
a tendency to bedsores in the latter stages. The power of
assimilating a vast quantity of food and of rapidly increas-
ing in general bulk is most extraordinary in this disease.

2. In Epilepsy. In only one case of this disease have I
seen persistent refusal of food ; in nearly all the appetite
tends to voracity. I hold the opinion that a reasonable
restriction in diet is also necessary in this disease. A great

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On the Appetite in Insanity,

increase in fatness renders life more uncertain in epileptics,
and I believe a surfeit may induce a succession of fits, and
thus cause death. I recollect on two Christmas Days
several years ago, a patient, after partaking too well of
plum-pudding, succumbed to a succession of fits ; post-mortem
examination showed the stomach overloaded with plum-
pudding ; since then I have even put a restriction on the
Christmas dinner of this class.

3. In a limited number of cases of Chronic Mania the
appetite is truly extraordinary. I have at present a private
patient who eats two rations to each meal without either
gain in bulk or making himself ill.

4. In the large number of Melancholiacs that come under
care, want of appetitite is one of the most marked features
in many cases ; both it and the melancholia probably result
from visceral causes. A good purge, a course of blue pill and
saline treatment frequently proves efficacious. A pretty
sensible melancholiac once told me if I just let him fast for
a couple of days his tongue would become clean, and he
would take his food ; but though this in his case turned out
quite true, the opposite is usually the rule.

5. Cases of Mania exist, and every now and then come
under treatment, where certain delusions are so strongly
held that they constrain the patient to overcome the feelings
of natural hunger; such as when he thinks he is com-
manded by the Almighty not to eat for a given time — usually
it is 40 days — or that he has no stomach, &c.

Recorded cases of sane sufferers from starvation state that
the feeling of thirst is more severe than hunger, and that
the pangs of hunger pass off after a limited time. I have
in a former paper detailed the experience in this asylum as
to forcible feeding, and the class I allude to here I always
feed on the third day of abstention. I have had to feed less
frequently during the past 18 months than ever previously
in my asylum life, the " tube " only having been used in five
cases. Of course feeding comes in runs, but I also think
that, as one gains in experience, feeding is not so fre-
quently required. Nurses press food better on patients;
the obnoxious and deterrent effect of an enema of food is
tried previous to feeding, and practically one does not feed
so many cases; at least J, with a larger asylum, do not, and
yet 1 do not let patients completely want for more than three
days.

6. In cases of youths who Masturbate we often find

by J. A. Campbell, M.D.

7

voracity and extreme emaciation coexist. A satisfying,
yet non-stimulating, diet is now quite recognised to be the
correct thing for such cases — a farinaceous and milk diet, and
little or no flesh food.

7. In my experience I have met with cases in which the
excitement has been so intense, and the patient has been so
restless, and talked so incessantly and rapidly that he seemed
really not to have time to swallow. I have seen at least one
case of this nature in which, owing to the patient being
almost choked by the efforts made to spoon food into him, I
have had to use the " tube." I should say that most probably
the excitement entirely did away with the feelings of hunger
in such a case.

8. I believe certain cases occur in which the absorbents
fail to act, the nerve-supply which should reach them
being misdirected, and acting to a fearful excess in other
directions. I should think that this must really be the case
in certain cases of acute and persistent excitement, as well
as in certain cases of acute melancholia. Teed such cases
how you will, little benefit seems to result. I believe this
really is the explanation of the tolerance that certain cases
exhibit to heavy doses of narcotics and to noxious sub-
stances picked up and eaten during attacks of excitement,
such as the eating of laburnum and other injurious seeds
without discomfort. I have had melancholiacs under my care
who, though properly fed, have yet become weaker, and
died without apparent lesion; and a marked case of the
type I allude to occurred four years ago under my charge.
A young lady, of a highly nervous organisation, became
acutely excited. I fed her from an early period of her attack
with most nourishing food and stimulants, and yet she died
without apparent cause other than the excitement. In this
case I rather regretted not having tried the effects of
mechanical restraint. At the post-mortem I found un-
digested fluid food in her stomach, and in the course of the
whole intestine. Both large and small intestines were un-
commonly dilated. I believe the nerve-energy expended in
her excitement had prevented the normal action of the
intestines, and that her death really resulted from this.

I think it highly probable that want of action of the
absorbents really accounts for the absence of ill effects in
those patients that Dr. Clouston * describes as daily taking

* " Edinburgh Asylum Report for 1881."

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On the Appetite in Insanity.

16 eggs and eight pints of milk ; few healthy people could
do it.

9. I do not enter on this subject at any length ; it is dis-
agreeable and loathsome. That creatures originally made in
God's image should so far descend in the scale, owing to
disease, as to eat with relish the most filthy, disgusting, and
unnatural things is a matter of deepest regret. I have
patients under my charge at present who I have seen eat
their own faeces, drink their urine from the pot, and, even
more abominable still, I have one patient who has to be
watched to prevent him from emptying the spittoons. Such
cases are truly horrible, and fill one with intense sadness
that human nature can descend to such an abyss. Though
I have frequently read of masses of hah*, cloth, &c, being
found in the stomachs of patients dying in asylums, only one
such case has come under my observation, though post-
mortem examinations are the rule in the Carlisle Asylum. A
report of this case will appear in the July number of the
"Journal of Mental Science." In this case I considered
death to have resulted from slow starvation, caused by the
presence of an accumulation of hair, string, and portions of
blankets in the stomach.

If my paper elicits from those I see here an expression of
opinion on the points touched on, it will have done its work
well, even if my views on many of the topics are not at all
borne out by others.